Germline genetic variants that impact cancer risk, prevention, and treatment strategies are implicated in up to 20% of cancers; however, only a fraction of people at risk for hereditary cancer syndromes undergo diagnostic genetic testing. Barriers to testing, at both the patient and provider levels, include gaps in knowledge and poor access to specialty genetics services. This multiphase project seeks to employ practice-level and patient-level interventions to increase the proportion of patients in whom family history is documented and assessed for genetic risk and in whom guideline-concordant genetic evaluation is completed. This proposal leverages existing partnerships between a statewide oncology network, public health agencies, payers, and a multidisciplinary team at the University of Michigan to encourage systematic family history ascertainment and genetic risk assessment among newly-diagnosed cancer patients cared for in 68 medical and gyn-oncology practices. In partnership with the Michigan Department of Health and Human Services and a network of nearly all oncology practices in Michigan, the Michigan Oncology Quality Consortium, we will deploy interventions to promote collection and assessment of family history and genetic evaluations for eligible patients with breast, colorectal, ovarian, prostate and endometrial cancer cared for in diverse clinical and geographic settings across the state. The first Specific Aim is to test the impact of innovative practice-based interventions on the proportion of patients who have a comprehensive family history documented in their medical record. In the first phase, using a stepped-wedge design, we will provide a tablet-based family health history survey tool to practices and evaluate the impact of the tool on quality measures of family history documentation and guideline concordant genetic referrals. In the second phase, at Year 4, we will test the impact of adding value-based reimbursement using family history ascertainment as the quality improvement metric. The second Specific Aim is to evaluate the impact of two behavioral interventions (tailored messaging via mobile optimized web interface vs genetic counseling using motivational interviewing) on uptake of genetic testing among patients with cancer who meet clinical criteria and disclosure of genetic test results to at-risk relatives. Our third Specific Aim addresses longitudinal follow up of cancer patients, exploring uptake of cascade genetic testing in families with germline mutations. These projects directly address implementation and dissemination of genomic medicine in diverse settings and will leverage both new and well-established partnerships among community and academic oncology practices, public health agencies, and payers in the state of Michigan. The University of Michigan is a leader in genomic medicine, behavioral interventions with diverse populations, healthcare policy, and implementation science, and the proposed work engages multidisciplinary expertise in caring for a diverse patient population and developing sustainable and scalable approaches for precision oncology in diverse healthcare settings.